What is the recommended waiting period after stopping a heparin (Heparin Sodium) drip to resume Eliquis (Apixaban)?

Timing of Apixaban Resumption After Heparin Drip Discontinuation

Apixaban (Eliquis) should be resumed 6 hours after stopping a heparin drip, following assessment of bleeding risk and confirmation of adequate hemostasis. 1

Rationale for Timing

The timing of anticoagulant transitions is critical to minimize both thrombotic and bleeding risks. When transitioning from heparin to apixaban, the following factors should be considered:

• Heparin pharmacokinetics: Unfractionated heparin has a short half-life of approximately 60-90 minutes, with most of its anticoagulant effect dissipating within 4 hours after discontinuation 1
• Apixaban onset: Apixaban reaches peak plasma concentration within 3-4 hours after oral administration 2
• Overlap considerations: Minimal overlap between anticoagulants reduces bleeding risk while maintaining anticoagulant coverage

Transition Protocol

1. Discontinue heparin infusion
2. Wait 6 hours after heparin discontinuation 1
3. Assess hemostasis - ensure no active bleeding
4. Administer first dose of apixaban at the appropriate dose based on indication:
   • 5 mg twice daily for most patients with atrial fibrillation
   • 2.5 mg twice daily for patients with at least two of: age ≥80 years, weight ≤60 kg, or serum creatinine ≥1.5 mg/dL 2

Special Considerations

High Thrombotic Risk Patients

For patients with very high thrombotic risk (recent thrombosis within 1 month, mechanical heart valve, or atrial fibrillation with recent embolic event):

• Consider a shorter transition period of 4 hours if bleeding risk is low 1, 3
• Monitor more closely for signs of thrombosis during transition

High Bleeding Risk Patients

For patients with elevated bleeding risk:

• Consider extending the transition period to 8-12 hours
• Ensure complete heparin clearance before initiating apixaban 3

Common Pitfalls to Avoid

• Premature apixaban initiation: Starting apixaban too soon after heparin discontinuation can increase bleeding risk due to anticoagulant overlap
• Excessive delay: Waiting too long between heparin discontinuation and apixaban initiation may create a window of inadequate anticoagulation, increasing thrombotic risk
• Failure to adjust for renal function: Apixaban dosing and timing may need adjustment in patients with severe renal impairment 2
• Inadequate communication: Ensure clear documentation of exact timing for heparin discontinuation and planned apixaban initiation

Monitoring Recommendations

• Observe for signs of bleeding or thrombosis during the transition period
• No routine laboratory monitoring is required for apixaban, unlike warfarin 2
• For patients with high bleeding or thrombotic risk, closer clinical monitoring is warranted during the first 24-48 hours of transition

By following this protocol, the transition from heparin infusion to apixaban can be accomplished safely while maintaining appropriate anticoagulation coverage.